Pelvic Organ Prolapse

Introduction

Pelvic organ prolapse is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis.

The pelvic structures that may be involved include the uterus (uterine prolapse) or vaginal apex (apical vaginal prolapse), bladder and anterior vagina (cystocele), and/or rectum and posterior vagina (rectocele).

The pelvic organs are normally supported and kept in their original position by muscles and ligaments of the pelvic floor.

When there is damage or weakening of these supporting structures, these organs are pushed down towards the vaginal opening.

Many women may have some degree of prolapse when examined; however, most prolapses are not clinically bothersome without specific pelvic symptoms, and they may not require an intervention.

Types of Prolapse

Not all genital prolapses are equal.

They are classified according to severity or degree of prolapse and can vary from very mild to severe.

For clinical and scientific reasons, more detailed and intricate classification systems are used.

In addition, the prolapse is different depending on where the pelvic floor weakness or damage is and which organ or organs have moved.

Uterine prolapse: involves the descent of the uterus and cervix down the vaginal canal due to weak or damaged pelvic support structures. Cystocoele: involves the descent of the bladder and can be noted as a bulge over the anterior vaginal wall. Sometimes the urethra (small tube from where the urine exists the bladder) is also prolapsed and we use the term Urethrocystocoele.

Rectocoele: involves the descent of the rectum and can be noted as a bulge over the posterior vaginal wall.

Enterocoele: is similar to a rectocele, but instead involves a higher part of the vagina and the organ pushing down is the small bowel and not the rectum.

Vaginal vault prolapse: this happens in women who have had a hysterectomy and no longer have the uterus. The top of the vagina descends into the vaginal canal.

Causes of Prolapse

Genital prolapse ultimately happens when there is damage or weakening of the muscles and other structures that support the pelvic organs.

Factors that contribute to the problem are:

Pregnancy and Childbirth probably the most significant cause for prolapse. Pregnancy by itself can contribute to the weakening of the pelvic floor due to hormonal changes and the extra weight and pressure of the baby. The risk increases with vaginal deliveries, number of pregnancies, delivery of large babies, prolonged second stage (pushing stage) of labour and forceps delivery. Quite often the damage that occurs during pregnancy and childbirth goes unnoticed at the time with symptoms only developing later in life.

Menopause/Ageing: The female hormone oestrogen plays an important role in maintaining the strength of the pelvic floor. After menopause, when the ovarian production of oestrogen decreases, the pelvic floor tissues becomes weaker. This may aggravate existing damage and trigger prolapse symptoms which were not noticeable before.

Increased Abdominal Pressure: An increase in intra-abdominal pressure puts strain on the pelvic floor and perineal muscles. If this is significant or sustained over long periods of time, it can exacerbate the prolapse. Some conditions where this could be the case include: obesity, chronic coughing associated with smoking or bronchitis, occupations that require intense physical work or heavy lifting.

Genetic Factors: Some women are born with deficiencies in some of the proteins that make up the connective tissue. They can present with weak bone joints and less resistant ligaments predisposing them to prolapse. This can happen as a result of events that usually would not cause prolapse in other women. Congenital weakness explains why some young women and women who have never had children develop a prolapse.

Symptoms

Genital Prolapse symptoms vary according to the degree of severity of the prolapse and also depending on which organs have changed position. In addition, different women may report different symptoms for similar clinical presentations.

The most common findings are:

The presence of a lump or bulge in the vagina or vaginal entrance.

A dragging sensation or feeling that something is falling or pushing down.

Pain is usually not very severe and is commonly felt as a dull backache or aching discomfort in the pelvic region.

Sexual problems - prolapsed pelvic organs can limit the depth of penetration or make penetration difficult or painful. The loss of pelvic tone can result in decreased sensation. Women with urinary incontinence may experience urine leaks during intercourse.

Emotional problems - prolapse can eventually lead to a loss of self-esteem and a negative self-image. There can also be loss of sexual enjoyment and desire.

Prolapse symptoms may vary over time and even during the day.

They tend to be more noticeable after long periods of standing or at the end of a working day.

Other factors that can make symptoms more pronounced or more noticeable are exercise, physical exertion and repetitive sneezing and coughing.

Diagnosis

For most women the diagnosis can be done by physical examination. In addition to a general and abdominal inspection a thorough gynaecological examination is essential. The doctor examines the woman lying down and, if necessary, standing up. Some manoeuvres such as asking the woman to cough or strain my help. In a few cases, it may not be obvious which organ is prolapsed and imaging such as 3D ultrasound or MRI can be used for a more accurate diagnosis.

Treatment

Genital prolapse is not a life threatening disease.

It may cause considerable discomfort, but most times there are no major implications for a woman‘s health.

The treatment will depend on the degree and type of prolapse, severity of symptoms and also patient’s and doctor’s preference.

Possible treatment options include:

Conservative and life style changes such as diet, weight loss and pelvic floor exercises can significantly help symptoms.

Intra-vaginal ring pessaries can be used to mechanically reduce the prolapse. This option doesn’t fix the prolapse itself but may be very effective at alleviating symptoms. It is recommended as a temporary measure for women while they wait for surgery or as an alternative for women who cannot or do not want to undergo surgical treatment.

Surgery: For decades surgeons have been using surgical procedures to treat prolapse. These include several different types of operations depending on the type of prolapse, patient conditions and surgeon’s preference. The last 10 to 15 years have seen major changes in traditional prolapse surgery. The main problem with traditional techniques is the high rate of recurrence of the prolapse (in the order of 30 to 50%). Several new surgical techniques have been made available. They involve not only new procedures, but also the use of biological and synthetic grafts.

Please refer to the Minimally Invasive Surgery page for a more detailed explanation of surgical procedures.

Frequently Asked Questions

How do I know if I have genital prolapse?

The most common symptom is the sensation of a bulge or of a round structure protruding through the vagina. This is often accompanied by a dragging sensation down the genital area. The first thing to do in order to confirm the diagnosis is a physical examination by your GP or gynaecologist.

What are the different forms of prolapse?

The four main organs that can prolapse through the vagina are the uterus, bladder, rectum and small bowel. The names given to the prolapse of these organs are uterine prolapse, cystocoele, rectocoele and enterocoele respectively. Most women will have a combination of two or more. Prolapses are then classified according to the degree of severity using different classifications.

Does genital prolapse need to be treated?

Not necessarily. The decision to undergo treatment for prolapse must be made by the woman in conjunction with her doctor taking into account the severity of symptoms and their implication on her quality of life. Except for very rare and unusual circumstances, prolapse is not life threatening and is not an urgent condition. There is always time to evaluate all options before deciding what to do.

What treatments are available for prolapse?

Conservative or non-surgical treatment includes changes in lifestyle, diet, weight loss, pelvic floor exercises and the use of hormone containing vaginal preparations. The prolapse can be mechanically reduced by the use of an intra-vaginal ring pessary. Some women may decide that the best treatment for them is an operation. When well indicated and competently executed, prolapse surgery can achieve excellent results. Patients are encouraged to take an active role and fully participate in the decision process that may lead to surgical treatment. This is the recommended approach for most things in modern medicine and even more so for the surgical treatment of prolapse.

Do I need to have surgery?

Again, not necessarily. And even if surgery is required it is by no means urgent. Surgical treatment can be very effective and is usually recommended when the perceived benefits of the treatment outweigh the potential risks of the procedure.

How and why is mesh used in prolapse surgery?

Synthetic grafts or mesh tend to achieve better surgical outcomes with reduced prolapse recurrence rates. On the other hand, the surgical complications can be more severe. At present there is no consensus as to when mesh should be used. The tendency among surgeons is to recommend it when the risk of prolapse recurrence is high or when using the woman’s own tissues is unlikely to provide good surgical support. These include recurrent prolapse after a previous operation, genetic predisposition to prolapse and severe or high grade prolapse.

What is the success rate of surgical treatment?

These vary enormously depending on several factors. Large studies of women who had traditional prolapse operation without mesh show a success rate of around 60 to 75%. Around 1 in 10 women who had prolapse surgery require a repeat operation later in life. Mesh surgery has not been around long enough for a reliable evaluation, but several studies have been done showing success rates in the order of 85 to 90 %.

What are the possible complications of prolapse surgery?

As with any operation there are the risks of bleeding and infection. Severe bleeding requiring a blood transfusion is rare and quoted as 1/300 cases. Antibiotics are routinely used to prevent infections.

Other risks include damage to nearby organ such as the bladder and the rectum. If noted at the time of surgery and properly fixed they usually do not have any long term consequences. The use of mesh adds the risks of mesh erosion (pieces of mesh coming out through the vaginal skin), infection around the mesh and mesh retraction (contraction and scaring of the tissue around the mesh). These are rare complications but potentially serious.

Not so much a complication, but a poor outcome of surgery is the recurrence of prolapse. As mentioned before, some women do not achieve the expected results form surgical treatment and a number of them may require further surgery. The main reason is the fact that the pelvic tissues are week and damaged, making it difficult to use them to provide the necessary scaffolding for pelvic organ support.